Trendy plans lead patients to skip care

High-deductible health plans are booming in popularity, now covering nearly one-third of Americans who get health insurance through employersponsored plans.

The high annual deductibles-an average of $4,647 for families-encourage consumers to think twice about running to a doctor every time they get a cold, and to shop around for the lowest prices on drugs, X-rays and surgeries.

But there's a big flaw in the way the plans are playing out. In an effort to save money, too many people are skipping preventive care-including exams, immunizations and cancer screenings. That's even though such visits are covered 100 percent without any out-of-pocket costs.

According to a new national study conducted by researchers at IUPUI, people on high-deductible health plans are cutting back on preventive care, and need to be educated on the fact that such care does not incur out-of-pocket costs. The research was published in the October issue of Health Affairs.

The skimping on preventive care could be a huge problem, as health officials routinely encourage people to get regular exams and screenings to catch problems early before they become serious and expensive.

The 100 percent coverage is required by the Affordable Care Act. It mandates that private insurance plans cover a broad swath of preventive services-from flu shots and colonoscopies to mammograms and prenatal care-without any patient cost-sharing, removing a barrier that once prevented many people from getting routine, preventive care.

Yet, too many people are still going without, not realizing they aren't on the hook for such services.

The IUPUI researchers said they did not expect to find that people were avoiding exams and flu shots for fear of having to pay out of pocket.

"We just wanted to see if high-deductible health plans were working," said Nir Menachemi, professor of health policy and management at the Richard M. Fairbanks School of Public Health at IUPUI. "Much to our surprise, we found that people were utilizing less preventive care. It's a serious problem."

The researchers reviewed 28 in-depth studies on high-deductible plans, to see if the plans were reducing the cost and use of care, one of the goals of high-deductible plans.

High-deductible plans are usually coupled with health savings accounts, so consumers can pay for health services with pretax contributions from employers.

The plans have lower monthly premiums than traditional health insurance, making them attractive to people who don't expect to need a lot of health care. But there's a trade-off: Consumers usually have to pay a lot more out of pocket for many services- such as visits to an urgent care center, hospitalization or chronic care-before the insurance kicks in.

The Internal Revenue Service defines a high-deductible plan as one with a minimum deductible of $1,300 per year for individual insurance coverage and $2,600 for a family. But they can be much higher, and the average today for family coverage is nearly $5,000, according to the Kaiser Family Foundation.

Those steep deductibles are meant to encourage people to shop around for the best price on health services. In addition, people who don't spend all the money in their health savings accounts can roll it over.

But in reality, the high deductibles sometimes discourage people from seeking the care they need, including free preventive care.

The IUPUI study found that highdeductible health plans were associated with a significant reduction in preventive care in seven of 12 studies and a significant reduction in office visits in six of 11 studies.

The study did not say how many people avoid preventive care, or whether people were aware that high-deductible plans offered free preventive care.

"Our study was not designed to find out why high-deductible health plans are working or not," Menachemi said. "Our study was designed just to find out whether the plans are working [in reducing use and cost of care]."

Some Indiana doctors said they weren't surprised by the findings, since they often encounter patients who don't know preventive care doesn't have an out-ofpocket cost.

The findings show that more patient education is needed, said Dr. John McGoff, an emergency room physician at Community Health Network and president of the Indiana State Medical Association.

"Preventive care is key," he said. "Too often, people don't realize they have hypertension or high blood sugar until they have big health problems and we see them downstream in the emergency room."

Another snag: Primary care visits are not always the same thing as preventive care visits, said Dr. Teresa Lovins, president of the Indiana Academy of Family Physicians, who has a practice in Indianapolis. Some visits to a primary care physician, such as for managing chronic conditions, will require out-of-pocket costs.

"Over time, patients confuse the two, and just avoid office visits altogether," Lovins said.

State statistics show patients are visiting the doctor less for many types of preventive care. The percentage of females age 50 to 74 who got a mammogram in the previous two years dropped from 75.4 percent in 2012 to 72.5 percent in 2016, according to the Indiana State Department of Health.

Likewise, the number of adults in that age group who got a blood stool test within the past year dipped from 8.8 percent in 2012 to 7.8 percent in 2016.

But in some other categories-such as adults getting routine checkups or colonoscopies-the number actually climbed slightly over the four years.

That information was collected as part of the state's Behavioral Risk Factor Surveillance System survey of several million residents. The survey did not say why the numbers changed.

Insurers say they are trying hard to educate their customers about the importance of preventive care-a message that becomes even more important as the ranks of Americans with high-deductible plans swell.

In 2006, just 4 percent of people with employer coverage had high-deductible plans. Now the proportion is 28 percent, according to Kaiser Family Foundation.

Minnesota-based UnitedHealthcare, the nation's largest health insurer, said highdeductible plans now account for about 40 percent of the people it covers.

"We want people to have those physicals," said Dan Krajnovich, UnitedHealthcare's president of Indiana operations. "That's where a doctor can identify certain things at an early stage, before they become more costly and lead to poor quality of health,". Krajnovich

Columbus is helped by the fact that The Ohio State University is downtown, Gigerich said. As a major research university, the school is a driver of that city's economy.

Columbus also has more headquarters of publicly traded companies than does Indianapolis, Gigerich said. Those include Huntington Bancshares Inc., utility company American Electric Power Co. Inc., manufacturer Mettler Toledo International Inc. and retailer Big Lots Inc.

But Indianapolis has strengths of its own.

Compared with Columbus, Gigerich said, Indianapolis has a stronger downtown, a better airport and a faster-growing information technology sector.

According to BEA data, Indianapolis' professional and business services sector-which includes the tech industry- grew 5.8 percent in 2016. It accounted for $13.9 billion of the metro's GDP last year, making it one of the area's largest industry sectors.

Krauss said she expects this sector to maintain its momentum in 2017, in part because of ambitious expansion plans by Salesforce and Infosys Ltd.

"That's where we are seeing great opportunity, great growth," Krauss said of tech.

Salesforce in May 2016 announced that it planned to hire 800 more Indianapolis workers over five years. In May of this year, India-based Infosys said it planned to open an $8.7 million technology and innovation hub in the Indianapolis area, hiring 100 by the end of this year and as many as 2,000 people by 2021.

Overall, however, Indianapolis' growth has paled in comparison to that of the Nashville-Davidson-Murfreesboro-Franklin metro area. Its 3.4 percent growth last year lifted that region's GDP to $109.4 billion, putting it 33rd in the nation.

The Nashville area's economy is booming because it is seeing population growth in most of its Hicks metro counties, said Michael Hicks, director of the Center for Business and Economic Research at Ball State University. In comparison, Indianapolis' suburban growth is in pockets.

From 2010 through 2016, the Indianapolis area's population increased more than 116,000, climbing to 2 million. However, four of 11 counties lost population: Brown, Madison, Putnam and Shelby.

Over the same time, the Nashville area gained more than 194,000 people, reaching 1.9 million. And only one of its 14 counties declined in population.

Without population growth, Hicks said, it's difficult to have economic growth: "It takes people to produce goods and services."

Another potential impediment to growth is a shortage of workers with the proper education and training to fill openings.

Over the next decade, Gigerich said, the Indianapolis region will need to fill 1 million jobs, with more than half of those vacancies-700,000-due to retirements.

The state needs to re-examine training programs for high school students and beyond, with a goal of steering more into high-wage, in-demand jobs, said Brian Burton, president of the Indiana Manufacturers Association.

Burton noted that, statewide over the next 10 years, 40 percent to 45 percent of workers across all industries will be retiring.

"We need to address the workforce issue," he said.

Manufacturing contributed $23.2 billion to the Indianapolis-area economy last year, which represents 0.3 percent growth over 2015.

But GDP figures for manufacturing can be affected by a variety of factors-including the timing of orders and changes in what items are produced-and Burton said the sector actually is doing better than that figure suggests.

He noted that, in the 12 months that ended in August, the manufacturing workforce grew 2 percent, to 92,700 jobs.

"It was a very minor [GDP] change, but we had job growth and we had wage growth, and that adds value," Burton said. "You blend this information together to get an understanding of where the economy's going. The outlook for Indiana is continuing strong manufacturing growth."